County Services--and Budget--in Limbo : Health care: Indigent patients face crisis as officials search for state and federal aid to keep system afloat. Others see an opportunity to restructure the system with fresh ideas.

With adoption of a new county budget, the health care delivery system for hundreds of thousands of indigent Los Angeles patients will be in a state of extreme uncertainty for months.

Long lines, denial of health care and months of chaotic upheavals is the very least that county officials say can be expected by those who rely on its health centers and hospitals.

Beyond that, no one knows for sure.

Even more extreme cuts, possibly involving the closing of some hospitals, could be in store if additional funding from state and federal sources cannot be secured by the Oct. 1 deadline set by the Board of Supervisors to begin closing outpatient services at county clinics and health centers.

At the same time, there could be dramatic changes for the better, some say.

The county health system could be catapulted into a modern updating, marked by partnerships with private hospitals and health providers, governed by a new health authority and management structure.

That's the goal of Burt Margolin, a former legislator appointed Tuesday by the board to guide the county through the health care crisis.

But Margolin will have to work quickly, and his task is monumental: changing the direction of a huge health care bureaucracy and bringing in fresh ideas and approaches from the private sector.

"How fast can the county move? How fast does the county want to move?" Margolin asked, listing some of the questions that will be answered over the next few weeks. "You can't operate as if it is business as usual. . . . They are going to have to move faster than they ever have before."

Although the budget cuts in health services are technically on hold for 60 days--to give Margolin and others time to come up with millions in additional state and federal financial aid--health officials said that as a practical matter they will have to stop accepting new patients at county clinics and health centers around Sept. 1.

If no new funding comes in, the county would shut down 29 of 39 clinics, six comprehensive health centers and the bulk of outpatient programs at hospitals.

This would require finding alternative places for treatment for patients receiving ongoing care for cancer, diabetes, heart disease and other health problems.

Dr. Ronald Kaufman, chief of staff at the mammoth County-USC Medical Center, raised a question that he admitted he could not answer:

"How am I going to choose which cancer patients, which heart patients, which diabetes patients we are going to take care of?"

Patients who cannot be cared for at county clinics and health centers will be referred to private hospitals and clinics, or, if their condition is grave enough, to the emergency room of a county hospital.

At the county hospitals, treatment will go into what one administrator called "a crisis mode," meaning only the sickest, most desperately ill patients would be treated. Others would be sent to emergency rooms where waits of one or two days are commonplace now.

Exactly how many people would be pushed out of the county health system, and when, is unclear.

"I hope nobody is going to be denied treatment," said Board Chairwoman Gloria Molina shortly before the supervisors adopted the budget Tuesday. "What [patients] are probably going to get is they are going to get referred to another line to stand in, but it isn't going to be denial. We can't do that."

If patients are refused treatment at county facilities, private providers would be faced with either accepting patients with no means of payment, which they have historically been reluctant to do, or turning them away.

That is what is driving efforts by Margolin and others to work out a new kind of public-private partnership.

Several Southern California counties--Santa Barbara, Orange and San Diego--got out of the hospital administration business years ago and contract with private providers, like the University of California, to treat the indigent.

But those restructurings were tiny compared to changing the huge Los Angeles County health care bureaucracy, with an annual $2.5 billion budget and 28,000 employees.

Talks have been under way for weeks between county officials and the California Medical Center in Downtown, which has expressed an interest in taking over the Hudson and Humphrey comprehensive health centers in Los Angeles.

Other talks are under way with hospitals in East Los Angeles, the Antelope Valley and Long Beach. The AIDS Healthcare Foundation, which operates the county's largest private AIDS treatment and hospice program, has held what were described as "active conversations" with the county about treating AIDS patients now cared for in county clinics.

"We are dealing with a very large, well-entrenched bureaucracy that is very hard to turn around, and we have two months to do it," said David Langness, a spokesman for the Healthcare Assn. of Southern California. "But we have a real crisis that is going to result in a public health disaster if we don't address it. The incentives to negotiate a deal with the county have never been stronger than they are now."